What is Heart Failure

Heart failure is a serious chronic condition where the heart cannot pump enough blood to support the needs of other organs in the body.

What causes heart failure? The most common causes of heart failure in Europe include coronary heart disease, myocardial infarction (heart attack), congenital heart defects or damaged heart valves.

What are the symptoms of heart failure? Red flag symptoms include breathlessness, fatigue and swollen limbs. Signs of heart failure may also be associated with an underlying cardiac disorder.

How does heart failure manifest itself? Patients may have symptoms of heart failure for many years before receiving a proper diagnosis. Most often, heart failure is diagnosed when patients have an acute episode, due to worsening of their symptoms, and requiring emergency

Heart failure is a chronic condition characterised by acute episodes, which can lead to admission to hospital, putting the patient at
great risk of death and re-hospitalisation.

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What causes heart failure?

Heart failure can occur very suddenly or it can develop slowly over many years, and there are many different reasons why someone might be diagnosed with heart failure.

Heart failure is not an illness in itself, but is the end product of a number of illnesses which damage the heart and interfere with its normal functioning. Some of the most common causes of heart failure are illustrated in Figure 2.

Heart failure can also present with multiple co-morbidities such as anaemia and kidney disease. These co-morbidities make the management of heart failure more complex for patients and heath care professionals.

In addition to the causes shown in Figure 2, heart failure may also be caused by other factors – for example, by a virus that attacks the heart or as a result of heart problems that arise during pregnancy (peripartum cardiomyopathy). These underlying causes of heart failure are not preventable and can occur in people of any age.

Figure 2. Common causes of heart failure. Adapted from Cowie et al. 2014.

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What are the types of heart failure?

There are two main types of heart failure

Heart failure with reduced ejection fraction which happens when the left ventricle is enlarged and the muscle does not contract effectively. This means that a smaller proportion of the blood is ejected in each heart contraction. This type of heart failure is shortened to HFrEF and can also be known as systolic heart failure.

Heart failure with preserved ejection fraction is caused by enlargement of the left ventricle wall. This reduces the size of the ventricle, meaning that the volume of the blood ejected may be lower than normal, but the proportion of blood ejected is the same. This type is shortened to HFpEF and is also known as diastolic heart failure.

Figure 3. Diagrams of the heart showing normal functioning, systolic, and diastolic heart failure. (a) represents the normal functioning heart where approximately 50% of the blood is ejected as the chambers contract. (b) shows HFrEF or Systolic heart failure where the issue regards blood pumping. Enlarged ventricles mean that the contractility is reduced, and so a smaller proportion of the blood is ejected. (c) shows HFpEF or Diastolic heart failure where the issue refers to filling of the heart chambers. The thickened ventricle wall reduces the overall volume of blood in the ventricle, meaning the proportion of blood ejected is normal or close to normal and that pressure inside the heart may be increased. Diagram from Cowie et al, 2014.

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What are the symptoms of heart failure?

The three ‘red flag’ symptoms of heart failure are fatigue, breathlessness and swelling of the limbs (usually ankles).
These symptoms are often hard for patients to identify and they may not recognize the need to see a health practitioner quickly. Some patients (and doctors) may dismiss symptoms as the natural consequence of ageing.

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How is heart failure diagnosed?

Diagnosis of HF is difficult for health professionals as the symptoms are not specific to heart failure.

The non-specific symptoms in conjunction with low awareness of heart failure in the public and health care professionals means diagnosis is often delayed.

There is no one diagnostic test for heart failure. Many tests may be used to investigate and diagnose heart failure, including

Blood tests
These can show if heart failure or another condition such as anaemia, diabetes or liver disease is causing the symptoms. The most commonly used tests measure the presence of natriuretic peptides in the blood – namely the B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-pro-BNP). These hormones are released when the heart is diseased or under stress.

Breathing tests
To to rule out lung problems creating the breathlessness.

Chest x-rays
To see if the heart muscle is enlarged or for any abnormalities in the lungs.

Electrocardiogram
Looks at the electrical activity of the heart for abnormal rhythms caused by thickened or enlarged heart muscle.

Echocardiogram
Visualises the heart to show any abnormalities in ventricle volumes, valves and wall thickness. It is also used to see how well the ventricle is pumping blood around the body by looking at the ejection fraction. Echocardiograms are the method of choice when investigating heart failure for reasons of accuracy, availability, safety and cost.

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How is heart failure treated?

Treatment for heart failure is critical to improve survival and quality of life, relieve symptoms, prevent future hospital admissions for patients. Additionally, it is vital to treat any co-morbidity or underlying cardiac problems alongside the treatment for heart failure.

Treatments for heart failure are evolving all the time. For up-to-date recommendations from leading European clinical experts, see the European Society of Cardiology (ESC) guidelines.

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Can heart failure be prevented?

Some of the illnesses that cause heart failure can be prevented, and measures to prevent all these causes may help prevent development of heart failure. These include:

  • high blood pressure
  • coronary heart disease
  • diabetes
  • heart valve disease
  • heart muscle disease (e.g. alcohol-related)

However, some heart diseases that cause heart failure cannot be prevented – for example, heart failure may be caused by a virus that attacks the heart or as a result of heart problems that arise during pregnancy (peripartum cardiomyopathy). In these cases, heart failure cannot be prevented, however appropriate treatment and management remain critical to help improve outcomes for patients.

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Why is self-management important for people with heart failure?

It is likely that patients will have to follow a treatment plan with medication for the rest of their lives. And so when living with heart failure, self-management is very important. There are many ways in which patients with heart failure can help keep their condition under control

  • Limiting salt and alcohol intake
  • Quitting smoking
  • Monitoring body weight and tracking fluid intake
  • Regular physical exercise at appropriate levels
  • Taking medication as prescribed
  • Monitoring any symptom changes

Along with these self-management techniques, there will also normally be medicine to strengthen the heart.

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